Wolters Kluwer Health
may email you for journal alerts and information, but is committed
to maintaining your privacy and will not share your personal information without
your express consent. For more information, please refer to our Privacy Policy.

ER Goddess: Sleeping with the Enemy

Dr. Simonsis a full-time night emergency physician at Henrico Doctors' Hospital in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.

His rocking stopped. “The enemy?” The rain was falling on the trees in front of my porch and on his parade. “Why am I the enemy?”

“You know, clinicians vs. hospital administrators.”

“Really?” he naively asked. “Why don't clinicians like us?”

I was surprised he was so in the dark. Before that drizzly night, I never knew how infrequently administrators see our frustrations. Having worked more than 10 years of night shifts, I'd rarely talked to administrators, and had minimal understanding of their vantage point. Then, through the universe's infinite sense of humor, I ended up with one as my boyfriend.

It was beyond eye-opening to see things from his perspective. We weren't exactly whispering sweet ICD-10 nothings, but we did discuss ED staffing, EMRs, nurse retention, and the overabundance of bureaucracy in medicine. I enjoyed the opportunity to explain to a suit what it's like to be in the trenches.

“Look at how many boxes I have to click and how much time I spend looking for the right box,” I said, sitting next to him catching up on charts. He actually understood. He had heard it from many doctors and nurses already, and lamented with us the fact that corporate has deemed it cost-prohibitive to overhaul electronic charting. I was particularly proud when he told me he suggested that “doctors should have scribes because of how inefficient our EMR is” during an administrative brainstorming session on increasing ED efficiency. Turns out suits can indeed empathize.

One morning as I was catching up on charts and he was analyzing patient care finances, I commented on what I saw on our ED tracker. “Oh, look, they have three docs, a PA, and only 13 patients. If it were a night shift, I'd have all 13 patients by myself. They're spoiled on the day shift.” He perked up, seeing an opportunity for cost cutting. “How many nurses are there?”

When I told him there were four nurses plus a charge nurse and a triage nurse, he concluded that they were overstaffed. I was quick to remind him that the ED has to be ready for anything 24/7, and staffing must prepare for the inevitable surges, not just the averages. Even an administrator could appreciate the necessity of having EDs staffed and ready for worst-case scenarios.

What really drove the staffing message home was explaining to him how understaffing drives nurses away. All administrators grapple with nursing shortages. Many learn the hard way that a hospital won't retain good nurses if it doesn't treat them or pay them right. Holes on the nursing schedule leave administrators struggling with the cost of overtime and travelers, and they leave clinicians struggling to keep up. They look at nursing turnover from a cost standpoint and we see it from a patient care one, but we can agree on the benefits of retaining hospital staff.

The Business of Health Care

Administrators genuinely do want to take care of hospital staff, but health care is to a large extent a business. None of us can escape the benefits of rationing FTEs, enforcing metrics, and controlling costs when it comes to a hospital's financial success. My boyfriend, like many administrators, found himself stuck between the wards and Wall Street. Like us, he is frustrated that employees' interests are supplanted for the interests of shareholders. But that is today's health care system.

The real enemy in the health care system is those who add layers of managerial garbage to patient care, including insurance companies and government regulators. Even administrators are frustrated by the unnecessary layers of bureaucracy burdening our health care system. “It's so hard to get anything done. Our corporate task force is doing the same thing as the local division, so we overlap, and national has to sort through who proceeds with what,” lamented my boyfriend in defeat one day as he got off a work call. The crossed lines of communication I witnessed illustrate what's wrong with health care. Clinicians and administrators agree with us that the red tape is ridiculous.

I realized I am lucky to be able to ignore the red tape. I blissfully go through a shift in the ED thinking only of medicine, not the burdensome office work that admin handles. I don't deal with insurance or costs, but treat everyone as needed. I try to be mindful of what I order, but it's from a less-is-more, limited-resources approach, not a financial approach. It became obvious how much we need financiers one night when our dinner conversation turned to observation vs. inpatient admissions from the ED:

“Why don't they reimburse for observation patients' home meds?” I asked.

“Because that's what's delineated in the billing code.”

“Who says?”

“Medicare,” he answered. Like many clinicians, I am overwhelmed by keeping up with Medicare, billing codes, and revenue. I would never want to crunch numbers to figure out that, as my boyfriend said, you end up with $400,000 to put toward patient care at an urban hospital if you charge $1 for the first 30 minutes of parking rather than making it free. I'd rather remove calculators from rectums than do those types of calculations all day. My relationship with the enemy has opened my eyes to how much we need our checkbook-balancing administrative friends.

Dating an administrator showed me that there are many similarities between our views, and we need them as much as they need us. We should stop looking at admin as an unapproachable group who doesn't understand physicians' priorities. The reality is individual administrators are good people who empathize with us. The key to bridging the two sides is communication. We need more doctors to be leaders who honestly tell admin what it's like to be in our shoes. If there's one thing I've learned from sleeping with the enemy, it's that they are willing to listen.